Search

Post-partum anaemia is an important global health issue. It is associated with increased maternal morbidity and mortality. This article focuses on the prevalence, causes and consequences of post-partum anaemia in Western countries. There is a need for national/international guidelines concerning the diagnosis, prevention and treatment of anaemia after delivery. In order to improve the mother's health status and quality of life, we suggest an increased awareness of diagnosing post-partum anaemia and use of evidence-based treatment options including oral and intravenous iron therapy.

In Denmark, the number of women in reproductive age having Roux-en-Y gastric bypass surgery increased in the period 2007-2010. The malabsorption related to the operation implies a predisposition to macro- and micronutrient deficiencies, which in pregnancy may influence the development of the foetus. The article concerns the need for managing the malabsorption syndrome, iron deficiency in particular, both in antenatal care, during pregnancy, delivery and in the lactation period. We suggest frequent follow-up in these patients and intravenous iron therapy, when oral iron treatment is inadequate.

Iron is essential for normal foetal development. Iron deficiency anaemia in pregnancy is a risk factor for preterm delivery and low birth weight in the newborn. Iron supplementation during gestation increases plasma ferritin and haemoglobin and reduces the prevalence of iron deficiency anaemia. As from June 2008, The Danish National Board of Health had been advocating general iron prophylaxis in pregnancy with 40 mg ferrous iron from the 10th gestation week to delivery. However, the authors suggest that individual prophylaxis according to plasma ferritin should be preferred to general prophylaxis.

The aim was to investigate the prevalence of anaemia in pregnant women emigrated from regions with a high prevalence of anaemia. Of a total of 1741 pregnant immigrant women referred to haemoglobinopathy screening, 406 immigrant women were included when matched by gestational age with a cohort of 205 pregnant ethnic Danish women. The prevalence of anaemia was 20.0% in the immigrant group compared to 4.9% among the Caucasian women, and iron parameters indicated iron-deficiency. Attention and nutritional counselling is thus needed on anaemia in this population group.

During the period 1984-2005, eight patients aged 25-57 years were treated for cardiac sarcoidosis. Diagnosis was obtained in three patients by endomyocardial biopsy, in three at heart transplantation (HTx) and in two at autopsy. Two patients had heart block, five ventricular arrhythmias and six dilated cardiomyopathy with congestive heart failure. Five patients died, one by sudden death, two of heart failure and two after HTx. Diagnosing cardiac sarcoidosis remains difficult, although MRI and PET scan have renewed the awareness of the disease.

The paper gives a review of the epidemiology, clinical manifestations, diagnosis, treatment and prognosis of cardiac sarcoidosis. Approximately 30% of patients with systemic sarcoidosis have granulomas in the myocardium, and 5% have clinical signs of cardiac affection. Cardiac manifestations comprise pericarditis, heart block, ventricular arrhythmias, valvular disease, ventricular aneurism, congestive heart failure and sudden cardiac death. Most frequent causes of death are sudden death and heart failure. Adequate treatment improves the prognosis of the disease.

Blau syndrome is a rare hereditary granulomatous disease presenting in patients of young age with exanthema, granulomatous arthritis and uveitis. Genetic analysis has shown an autosomal dominant inheritance and a number of specific mutations on chromosome 16q in codon 334, of which the most predominant are R334W and R334Q. Blau syndrome exists in Caucasian, Asian and Afro-American families, and de novo mutations have been reported. The estimated minimum incidence in Denmark is 0.05 per 100,000 person-years. Blau syndrome has pathological, clinical and therapeutic features in common with sarcoidosis but rarely involves the lungs or other parenchymatous organs. Discrimination between Blau syndrome and early-onset sarcoidosis should rely on chromosome analysis.

This case report describes Blau syndrome in monozygotic twins. The disease ran an identical course in both patients, starting with a maculopapulous exanthema at one year of age. Skin biopsies showed epithelioid cell granulomas with multinucleated giant cells. Shortly after arthritis and periarticular swelling developed and uveitis appeared at 8 years of age. Treatment consisted of prednisolone and methotrexate, and from 18 years of age of infliximab, with good effect. DNA analysis showed de novo R334W mutation in the CARD15 gene. The patients have now been followed for 19 years and are in good clinical condition.

Some patients with severe sarcoidosis are resistant to conventional treatment with corticosteroids and cytostatics. We describe a 29-year-old man with histologically verified sarcoidosis and persistent, pronounced enlargement of the peripheral lymph nodes, resistant to treatment with prednisolone and methotrexate. Following treatment with TNF-alpha-inhibitor (infliximab 3 mg/kg body weight), the lymph nodes regressed to normal size and the patient improved clinically. The patient had a total of four infliximab infusions, and the effect has persisted for more than two years.

The Danish Nutrition Council has examined the latest scientific literature on nutrition during pregnancy to evaluate the basis for the existing official recommendations. The recommendation to overweight women to gain only eight kilo should be accompanied with a recommendation to lose weight pre-conceptionally. Individualised recommendations should be provided in the prevention of iron deficiency, and the recommendation for calcium should include information on quantity. The recommendation of periconceptional folic acid supplementation does not benefit unplanned pregnancies. Arguments exist for adding a recommendation for vitamin D.

A 46-year-old man with hilar adenopathy had a flexible bronchoscopy and transbronchial forceps lung biopsy. After the procedure, the patient developed a haemopneumothorax.

Two patients presented with severe obstruction of the distal trachea and the main bronchi, owing to compression by an aneurysm of the descending thoracic aorta (patient 1) and the ascending and descending aorta (patient 2). Both patients died from combined respiratory and cardiac failure. Thoracic aortic aneurysm should be included in the differential diagnosis of subacute tracheobronchial obstruction.

We evaluated the influence of Helicobacter pylori (H. pylori) infection assessed by the levels of H. pylori serum IgG-antibodies, on iron status (serum ferritin and haemoglobin) in 2794 Danes (1425 men), aged 30-60 years. The seroprevalence of H. pylori antibodies increased with age (p < 0.01). Median serum ferritin levels were significantly lower in seropositive than in seronegative men and postmenopausal women (men 114 micrograms/L vs. 120 micrograms/L, p = 0.01; premenopausal women 37 micrograms/L vs. 40 micrograms/L, p = 0.13; postmenopausal women 63 micrograms/L vs. 77 micrograms/L, p = 0.02). Seropositive subjects had a higher prevalence of iron deficiency (serum ferritin < 15 micrograms/L) than seronegative subjects. H. pylori infection has a negative influence on iron status. We hypothesize that this may be caused by increased blood losses from the gastric mucosa.

The prognostic information provided by platelet counts was studied in 1115 patients with primary lung cancer and in 550 control patients with benign lung disorders. Patient records were retrospectively reviewed regarding histological tumour type, TNM stage, thromboembolic episodes and survival. The prevalence of thrombocytosis (platelet count > 400 x 10(9)/l) in patients with lung cancer was 32.1% vs. 6.4% in controls (p < 0.0001). Platelet counts increased with TNM stage (p < 0.0001). Patients with thrombocytosis had a shorter survival than patients with normal platelet count (p < 0.0001). Thrombocytosis was a predictor of short survival also when adjusted for tumour type, sex, age, and TNM stage (p < 0.001). The platelet count and the frequency of thrombocytosis declined after tumour resection (p < 0.0001). Thrombocytosis was not associated with thromboembolism. In conclusion, thrombocytosis is a clinically significant prognostic indicator regarding survival in patients with primary lung cancer.

The objective was to examine the relationships between serum ferritin, alcohol consumption and sociodemographic factors (school education, occupational education, occupation, income, marital status, cohabituary status, housing, social class) in a survey performed in Copenhagen County during 1982-1984. The participants, selected at random, comprised 2235 Danish Caucasian individuals, all non-blood-donors (1044 men, 1191 non-pregnant women) in cohorts 30, 40, 50 and 60 years old. In all age groups, men had significantly higher serum ferritin and alcohol consumption than women. In men, there was no relationship between serum ferritin and social class. Significant relationships were observed between ferritin and occupation (unemployed and self-employed men had the highest ferritin and ferritin and income (ferritin increased with income). None of the social variables were associated with the prevalence of small or absent iron stores (serum ferritin < or = 30 micrograms/l) or abundant iron stores (serum ferritin > 300 micrograms/l). Alcohol consumption displayed relationships to occupation and become, but not to social class. In women, none of the social variables showed any relationship to ferritin levels or iron overload. The prevalence of small iron stores was lower and the make of alcohol was higher in women from high social classes. In both men and women, serum ferritin displayed significant positive correlations with alcohol consumption. Likewise, the prevalence of iron overload was closely correlated to alcohol consumption. In conclusion, sociodemographic factors per se had a minor influence on serum ferritin levels and iron status in Danes. The distinct association between alcohol consumption and serum ferritin should be considered in future epidemiological iron status surveys.

Among fertile, nonpregnant, Danish women, 33% have absent or reduced iron stores; 22% have serum ferritin values above 70 micrograms/l, i.e., iron reserves of more than 530 mg, corresponding to the net iron losses during a normal pregnancy. During pregnancy, the demands for absorbed iron increase from 0.8 to 7.5 mg/day. Controlled studies show that iron-treated pregnant women have higher serum ferritin levels, i.e., larger iron stores, and higher haemoglobin levels than placebo-treated women. A supplement of 66 mg ferrous iron daily from the beginning of the 2nd trimester prevents iron deficiency anaemia. In Denmark, general iron prophylaxis with 60-70 mg ferrous iron daily from 20 weeks of gestation is recommended by the health authorities.

Mycobacterium marinum is a rare cause of disseminated infection in man. The case report describes an 80-year-old woman, who had been treated with oral corticosteroids for bronchial asthma for 40 years, and in the same period had been swimming daily in swimming pools. At the first admission, the symptoms and clinical findings were interpreted as seronegative rheumatoid arthritis. After eight years of disease with recurrent infections of the skin, periarticular tissues and joints in the hands and one elbow, a biopsy specimen from an abscess showed granulomatous inflammation and acid fast bacilli. Culture for mycobacteria grew M. marinum. There was a severe, destructive monoarthritis in the right second metacarpophalangeal joint. The patient recovered completely on treatment with clarithromycin and doxycycline.

Sarcoidosis is a granulomatous disease of unknown aetiology, which may affect various organs. The diagnosis is obtained by the demonstration of epytheloid cell granulomas in an affected organ. The incidence of sarcoidosis in Danish children less than 15 years of age is 0.22-0.27/100.000 children/year, corresponding to approximately three new cases in Denmark each year. The disease often takes an asymptomatic course. During the period 1980-1992, three cases of paediatric sarcoidosis were observed in Copenhagen Country. All three had pulmonary involvement, and one had severe hypercalcaemia. In children less than five years of age, the disease is characterized by involvement of lungs, lymph nodes and eyes. Treatment, which is symptomatic, consists of systemic steroids. Due to the risk of growth retardation, the indication for treatment should be carefully considered and steroids administered at the lowest effective dose. Due to the lack of follow-up studies, the long term prognosis is unclarified.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease of unknown aetiology. The clinical and paraclinical findings consist of recurrent haemoptysis, pulmonary infiltrates and iron deficiency anaemia. Examination of sputum or bronchoalveolar lavage fluid obtained at fiberoptic bronchoscopy discloses large numbers of haemosiderin-laden alveolar macrophages. Pulmonary interstitial fibrosis may develop. As pulmonary haemosiderosis can be observed in association with several diseases, IPH is basically a diagnosis made by exclusion of other causes. The treatment consists of immunosuppression with steroids and cytotoxic drugs.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease characterized by recurrent episodes of intrapulmonary bleeding, chronic iron deficiency anaemia and pulmonary fibrosis. IPH is a diagnosis made by exclusion of other causes. It occurs in both adults and children. Other conditions than IPH can cause pulmonary haemosiderosis. The etiology is unknown, but might be an immunological mechanism causing a defect in the basement membrane of the pulmonary capillary. IPH should be suspected in patients with recurrent episodes of coughing, haemoptysis, dyspnoea and anaemia. Chest X-ray shows pulmonary infiltrates during an acute attack. Examination of sputum or lung biopsy discloses large numbers of haemosiderin-laden pulmonary macrophages. The mortality-rate is high, but the prognosis is difficult to evaluate because many patients survive for a long time either with a course of recurrent attacks or with chronic symptoms, such as dyspnoea and persistent anaemia. Steroids may improve the condition of the patient during a bleeding episode.

The aim of this randomized, double blind, placebo controlled parallel study was to evaluate whether iron status markers in pregnant women, measured early in the second trimester, could be used to predict levels later in pregnancy, and post partum. One hundred and twenty healthy pregnant women between 14 and 18 weeks of gestation were included. Sixty-three women were allocated to treatment with tablets containing 66 mg ferrous iron (as fumarate) daily, and 57 women to treatment with placebo. Haemoglobin, serum transferrin saturation, and serum ferritin were measured every fourth week during gestation, prior to delivery, one week and eight weeks post partum. Correlation matrices during pregnancy and post partum were calculated for each iron status marker, both in iron and placebo treated women. Haemoglobin, transferrin saturation and serum ferritin values at inclusion displayed steadily declining correlation coefficients with values obtained later in pregnancy. There were no clinically relevant correlations to values obtained eight weeks or less prior to delivery, or post partum. Serum ferritin values at inclusion could not be used to predict values later in pregnancy or post partum. Haemoglobin, transferrin saturation and serum ferritin values measured in the beginning of the second trimester appear unsuitable as guidelines for an individual iron prophylaxis during the remaining period of pregnancy.

The diagnostic potential of secondary transthoracic needle biopsy (TNB) following negative fiberoptic bronchoscopy in patients with peripheral circumscribed pulmonary lesions was evaluated in a retrospective study. The records from 224 patients who had TNB performed over a five-year period were reviewed. Of these, 103 patients met the criteria for inclusion in this series. The overall diagnostic yield of TNB in malignancy was 73.8% (54 of 73 patients). TNB allowed cytological classification of the tumour type in 72.2% (39 of 54 patients). Five of the 54 patients (9.3%) presented with small cell anaplastic bronchogenic carcinoma, diagnosed by TNB, and were treated with chemotherapy. Of the 49 patients with a negative TNB, 27 went on to diagnostic surgical procedures; 19 had malignancy, three benign tumour, two infection, and three sequelae after pulmonary infarction. The remaining 22 patients with undiagnosed lesions were followed long term, five showed progression of the pulmonary lesion suggesting malignancy. TNB appeared unsuitable in the diagnosis of benign lesions. Unspecific inflammation was not considered evidence of benignity, and therefore a definitive benign diagnosis was not made by TNB in this series. There were no serious complications to TNB. In 18.1% of the procedures a pneumothorax developed, indicating a chest tube in 8.6% of the procedures. TNB is a suitable diagnostic procedure with a high diagnostic yield in patients with peripheral, malignant pulmonary lesions.

A 54 year-old previously healthy woman was admitted with staphylococcus aureus septicaemia. The patient had been treated with oral iron supplementation for two years due to fatigue. In the evaluation of postinfectious anaemia, serum transferrin saturation and serum ferritin were found persistently elevated with values of 74% and 950 micrograms/1, respectively. Hereditary haemochromatosis was suspected even though there was no history of liver disease or diabetes mellitus in the family. A bone marrow biopsy showed a normal content of haemosiderin iron. The liver biopsy revealed haemosiderosis, mainly located to the periportal hepatocytes, and fibrosis in the portal tracts. The HLA-type was A3, B7, B37. Over a period of ten months, a total of 3.9 g of iron was removed by venesection while S-ferritin declined to 31 micrograms/l. A sister to the proband had an identical HLA type, but normal iron status markers, either indicating heterozygosity or homozygosity with lack of penetrance. In preclinical hereditary haemochromatosis, early diagnosis and treatment is essential in order to prevent organ damage and to improve prognosis. Prophylactic screening is recommended. The identification of one homozygous subject in a Danish year-cohort of 60.000 persons costs approximately 40.000 Danish kroner (7.000 US+).

In this paper, we present two cases of extrapulmonary tuberculosis, the first case with tuberculosis of the larynx and the second with tuberculosis lymfadenitis. In both cases malignant lesions were primarily proposed. We emphasize that definitive diagnosis requires culture and specification of Mycobacterium tuberculosis. We draw attention to the fact that extrapulmonary tuberculosis is still a differential diagnostic consideration.

Iron status was assessed by measuring serum ferritin and haemoglobin in a population survey in Copenhagen County, comprising 1359 nonpregnant women in age cohorts of 30, 40, 50, and 60 years; 809 were premenopausal and 550 postmenopausal. Premenopausal women had lower serum ferritin (median 37 micrograms/l) than postmenopausal women (median 71 micrograms/l), p < 0.0001. Of premenopausal women, 17.7% had ferritin < 15 micrograms/l (depleted iron stores), and 23.1% had ferritin levels of 15-30 micrograms/l (small iron stores). Corresponding figures in postmenopausal women were 3.3% and 10.3%. Iron deficiency anaemia (ferritin < 15 micrograms/l and haemoglobin < 121 g/l) was observed in 2.6% of pre- and 0.36% of postmenopausal women. After menstruations had ceased, there was a steep rise in ferritin levels, being most pronounced during the first 7 postmenopausal years. Pre- and postmenopausal multipara had lower ferritin than nulli- and unipara (p < 0.04), indicating that pregnancy and childbirth had a long lasting reducing influence on iron stores. The use of oral hormonal contraceptives had a marked increasing effect on iron stores, being correlated to the number of years the women had been taking the pill.

Gaucher's disease is an autosomal recessive disorder caused by deficiency of the enzyme glucocerebrosidase with accumulation of glucocerebroside in the reticuloendothelial system. Affection of the lungs by this disease is extremely rare. When Gaucher cells infiltrate the lung, fibrosis may result. We describe a case with adult type Gaucher's disease who, besides affection of liver, spleen and bone marrow, had severe pulmonary involvement with extensive interstitial fibrosis, increased pulmonary vascular resistance, and pronounced reduction in diffusion capacity.

Fourty-three patients (28 males, 15 females, median age 50 years) with iatrogenic pneumothorax following invasive diagnostic procedures (percutaneous transthoracic fine needle aspiration biopsy 26, fiberoptic transbronchial biopsy 14, pleurocentesis 3), were treated with small calibre thoracic tube drainage. The tube consisted of a teflon catheter, 160 mm long, 2 mm in outer diameter which was inserted into the second intercostal space in the mid-clavicular line in local analgesia. Pneumothorax was evacuated by intermittent aspiration with a syringe in 16 patients. In the remaining 27 patients the catheter was connected to a one way flutter valve. Treatment was uncomplicated in all patients and successful in 41 (95%) patients, while two required a large calibre chest tube on account of persistent leakage. The median drainage time was 48 hours. Small calibre thoracic tube with a one way flutter valve is convenient for treatment of iatrogenic pneumothorax, being less traumatic and less expensive than conventional thoracic tube drainage.

Fiberoptic bronchoscopy was performed in local anaesthesia with lidocaine in 16 patients. Serum concentrations of lidocaine and its active metabolite monoethylglycinexylidide (MEGX) were measured at regular intervals up to 120 min. after administration. Lidocaine was administered as aerosol in the upper respiratory tract and as solution in the bronchial tree. The total lidocaine dose was 243-608 mg (2.4-8.0 mg/kg); 163-508 mg (1.6-6.6 mg/kg) was given as aerosol, and 60-180 mg (0.8-2.5 mg/kg) as solution. The highest median S-lidocaine concentration, 10.5 mumol/l, was measured 20 min. after administration. None of the patients had toxic S-lidocaine levels (greater than 26 mumol/l) and no adverse effects were observed. The highest median S-MEGX concentration, 1.7 mumol/l, was measured 120 min. after administration. The highest individual S-MEGX was 3.5 mumol/l. The highest, although insignificant, correlation coefficients were found between lidocaine dose expressed in mg/kg body weight and S-lidocaine and S-MEGX.

The clinical appearance of sarcoidosis and the changes seen on x-ray of the thorax are often typical. However, several other conditions may present the same symptoms and identical x-ray findings. The present case report emphasizes the importance of an invasive approach and of histological investigation in patients in whom carcoidosis is suspected. For almost one year, a man aged 29 years was considered to be suffering from sarcoidosis on account of the clinical symptoms and bilateral hilar adenitis on x-ray op the thorax. He was treated with steroid for several months with clinical and radiological response. After the illness has lasted for one year, bronchoscopy was performed and bronchial biopsies revealed the diagnosis of malignant lymphoma.

Pulse oximetry during fiberoptic bronchoscopy in local anaesthesia was performed in 81 patients (52 male, 29 female), median age 60 years (range 25-80); 18 had impaired lung function with FEV1 less than 50%. Premedication consisted of atropine, diazepam and midazolam. The arterial haemoglobin oxygenation (SaO2) was registered continuously. Supplementary oxygen in doses of 2 1/min was administered to 41 patients (group 1), while 40 patients were examined without oxygen (group 2). The two groups were comparable as regards sex, age and lung function. Mean values of SaO2 during bronchoscopy were higher in group 1 (median 96%) than in group 2 (92%) (p less than 0.001). Minimum values of SaO2 were similarly higher in group 1 (median 93%) than in group 2 (87%) (p less than 0.001). The percentage numbers of patients experiencing hypoxaemic episodes with SaO2 less than or equal to 90% and SaO2 less than or equal to 85% were 34% and 5% in group 1 compared to 80% and 35% in group 2, respectively (p less than 0.01). The decrease in SaO2 and the frequency of hypoxaemic episodes were highest in patients with impaired lung function. Supplementary oxygen in doses of 2-3 1/min and pulse oximetry are recommended as routine procedures during fiberoptic bronchoscopy in local anaesthesia.

Sarcoidosis is a systemic granulomatous disorder of unknown genesis with an average annual incidence of 10/100,000 population in Denmark. The clinical picture and prognosis are dominated by the pulmonary changes in the majority of cases. The patho-anatomical picture consists of a T-lymphocyte-dominated interstitial inflammation with non-caseating epithelioid granulomas followed by fibrosis in varying degrees. The different types and courses of pulmonary disease are reviewed. Clinical examination, chest radiography, pulmonary function tests (especially the carbon dioxide diffusion capacity) and S-angiotensin-converting enzyme (S-ACE) are the most important measures of disease activity. The value of systemic corticosteroids is critically evaluated; most patients in this country can be observed without treatment because the spontaneous resolution rate is high. It is recommended that steroids should be administrated primarily in symptomatic and progressive parenchymal lung disease, or when critical or disabling extrathoracic sarcoidosis is present. If the pulmonary parenchymal infiltrates do not disappear within approximately 18 months, a course of prednisolone for at least one year should be considered to prevent disabling or even lethal pulmonary fibrosis.

The article contains a review and two case reports of pulmonary histiocytosis-X. This is a rare disease entity comprising about 3% of all chronic interstitial lung diseases. Diagnosis is confirmed by histological and electronmicroscopic demonstration of the typical histiocytosis-X cell. The course of the disease varies. About 25% of the patients show spontaneous remission, in 40% the changes remain stationary, while 35% progress and eventually die from respiratory insufficiency or cor pulmonale. Treatment with glucocorticoids and cytostatics should be initiated at high disease activity, with progressive X-ray changes and decreasing pulmonary function.